Provider Demographics
NPI:1467068569
Name:CROSSTOWN DENTAL GROUP LLC
Entity Type:Organization
Organization Name:CROSSTOWN DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-881-1234
Mailing Address - Street 1:1350 CONCOURSE AVE STE 446
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2026
Mailing Address - Country:US
Mailing Address - Phone:901-881-1234
Mailing Address - Fax:901-339-5995
Practice Address - Street 1:1350 CONCOURSE AVE STE 446
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2026
Practice Address - Country:US
Practice Address - Phone:901-881-1234
Practice Address - Fax:901-339-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty